NIHR Global Health Research Group on homelessness and mental health in Africa (HOPE)

Co-occurrence of homelessness and severe mental illness (SMI) is a health and social emergency affecting an estimated 28-36 million people in low- and lower-middle-income countries (LLMICs)[6]. SMI includes disabling psychotic and affective disorders, often co-morbid with substance abuse. Homeless persons with SMI are at high risk of human rights violations, premature mortality and social exclusion. Absence of evidence on effective interventions is a potent barrier to global action. Research Question: How can unmet needs of homeless persons with SMI in LLMICs be addressed effectively in ways that are rights-based, contextually grounded, scalable and sustainable? Aim: To establish a new partnership of stakeholders across Ethiopia, Ghana and Kenya who are equipped to lead action research to improve the lives of homeless persons with SMI. Methods: To improve understanding of diverse contexts and ensure wider applicability of findings, we will work in a capital city in Ethiopia, a regional city in Ghana and a rural county in Kenya. We will build foundations for participatory working, equipping all stakeholders for inclusive work and empowering people with lived experience. Formative phase (Months 3-15): Formative work will include synthesis of global evidence (scoping & grey literature reviews) and experience (Delphi exercise). In the study sites we will map the context (documentary analysis, geography of homelessness, key actors & existing resources); a rapid ethnographic study to understand lived experience; survey of homeless persons (n=700 each in Ethiopia & Ghana; n=350 in Kenya) for prevalence of SMI, co-morbidity and prioritised unmet needs; and in-depth interviews and focus group discussions with key stakeholders to identify experiences, challenges and opportunities for intervention. This global and local evidence will lead to serial Theory of Change workshops to agree valued primary outcomes, map pathways to impact and inform selection of interventions and implementation strategies. Intervention co-production and piloting (Months 16-24): Intervention packages to address prioritised needs will be co-produced, piloted with 10-15 homeless persons with SMI for proof-of-concept, and optimised for feasibility and acceptability using participatory action research. A cornerstone of intervention is peer support. We will draw on experience with rights-based approaches and community-based care to ensure sustainability as an integrated service. Implementation and evaluation (Months 25-42): Implementation of the interventions will be phased to allow controlled evaluation up to 3 months and a pre-post intervention study over 6 months. We will recruit 1050 homeless persons with SMI and assess impact on the selected primary outcome, change in unmet needs, social inclusion, human rights abuses, home status, physical health, family reintegration, survival and societal costs. We will conduct a mixed methods evaluation of implementation processes and outcomes. Realist evaluation will analyse how contextual variation affects mechanisms and outcomes for global application. Impacts: (1) Evidence-supported interventions for homeless persons with SMI; (2) WHO manual on how to adapt & implement the programme in different LLMIC settings; (3) Innovative methods and ethical approaches; (4) Greater policy prioritisation; (5) 3 PhD/post-doc fellows and 3 peer researchers trained; (6) Strong partnerships and platforms for ongoing high-quality research at scale.